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Difficulty: MediumReduction of Risk Potential

A nurse is closely monitoring a client who is 4 hours postoperative following an open abdominal surgery. Which of the following assessment findings should the nurse recognize as early indicators of impending hemorrhagic shock? Select all that apply.

  1. Unexplained restlessness and agitationAnswer
  2. A progressive narrowing of the pulse pressureAnswer
  3. Mild tachycardia with a heart rate of 110 beats per minuteAnswer
  4. D
    A significant drop in systolic blood pressure to 82 mm Hg
  5. E
    Bounding, full peripheral pulses

Answer

The early indicators of hemorrhagic shock include unexplained restlessness and agitation, a progressive narrowing of the pulse pressure, and mild tachycardia.
In the early (compensatory) stage of hemorrhagic shock, the sympathetic nervous system activates to maintain adequate tissue perfusion. This results in mild tachycardia to increase cardiac output. Peripheral vasoconstriction increases diastolic blood pressure, leading to a narrowed pulse pressure. Additionally, subtle decreases in cerebral perfusion manifest early as restlessness, anxiety, or agitation.

Step-by-Step Solution

1
Identify the physiological changes associated with early (compensatory) shock.
The body activates the sympathetic nervous system in an attempt to maintain tissue perfusion and cardiac output.
Compensatory mechanisms mask significant blood pressure changes early in the process.
2
Analyze how these compensatory mechanisms manifest clinically.
Epinephrine and norepinephrine release causes an increased heart rate, peripheral vasoconstriction, and shunting of blood to vital organs.
This leads to tachycardia, cool skin, and a rising diastolic pressure (narrowing pulse pressure).
3
Differentiate between early signs and late (decompensated) signs.
Tachycardia, narrowing pulse pressure, and subtle cerebral hypoxia (restlessness) appear early. Severe hypotension and organ failure appear late.
Interventions must begin during the early phase before irreversible cellular damage occurs.

Key Concept

Early Recognition of Compensatory Shock
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Topics

Reduction of Risk Potential

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